ANÁLISIS EN VESTIMENTA

Increasing costs and morbidity related to frequency of prostatectomies have led to a search for tools for better evaluation, predictors of good outcome as well as to alternative treatment strategies. Symptoms lead the patient to seek treatment and symptom improvement is the chief goal for the patient.

Studies using symptom indices to measure symptoms, to assess severity of symptoms and the bother caused by them and to follow changes with time and perhaps treatment have been undertaken in men with diagnosed symptomatic BPH 10, 14, 61, 62.

Patient’s age distribution in this study is consistent with previous studies by others, which have shown that the prevalence of lower urinary tract symptoms suggestive of benign prostatic obstruction increases with age ^{16, 25, 63}.

5.1: Role of IPSS in initial assessment of patients.

It was possible using IPSS to categorize patients according to severity of symptoms into minor, moderate and severe groups and to also determine the level of bothersomeness of their symptoms. It is noteworthy that most of the patients (51.0%) fell into the moderate category and that the mean quality of life score increased with increasing mean IPSS. Spearman’s coefficient of 0.72 showed significant correlation between QOLS and pretreatment IPSS. The relative distribution of scores in this study is similar to the result seen in the study by McConnell et al ³⁰.

5.2: Role of IPSS in choice of treatment modality and monitoring response to therapy.

Prior to the 1980s, prostatectomy was the only widely accepted intervention for BPH. However, in men with symptomatic BPH, it is clear that progression is not inevitable and that some men undergo spontaneous improvement or resolution of their symptoms ⁶⁴ . Previously all these patients would have had prostatectomy whether it was actually indicated or not. This initial assessment result puts the urologist in a better position to understand the magnitude of the patients problem and expectation and to choose the appropriate intervention for the patient.

These patients were subjected to different management protocols based on their scores. The overall change in the pretreatment IPSS and quality of life scores for the 104 patients was found to be statistically significant (P<0.001) after 3 months of intervention.

There was worsening of patient’s symptoms as depicted by increased IPSS and QOL scores in the minor symptom category who were managed by watchful waiting for 3 months. However the number of patients in this group was too small to merit statistical analysis. Other studies have shown varying results with this category of patients. McConnell et al ³⁰ in their detailed review of interventions for BPH noted some improvements in symptoms in about 40% of patients studied but more than one-third of patients actually experienced deterioration under the watchful waiting strategy. Wasson et al ⁶⁵ also reported disease progression in 47% of patients randomized to watchful waiting. They attributed this to increasing

postvoidal residual urine (PVR) or symptom score. Conversion to other treatment protocol usually becomes necessary in such group of patients. However it is known that some group of patients experience no change in their symptom scores for several months ³⁰. Based on the findings in this study, alternative treatment protocols like alpha adrenergic blockers should be instituted for worsening symptoms in the mild group or even surgery if complications set in.

However, in our society patients usually present when their symptoms become a source of worry for them. Watchful waiting may not be a viable management option.

There was symptom improvement in the moderate symptom category treated with alpha adrenergic blocker. Doxazosin was used in this study. The mean magnitude of change in IPSS and QOLS; 8.1 (52%) and 1.7 (41%) was

statistically significant (P<0.001) and is comparable to findings in other studies.

Nwofor et al ⁴⁵ employed Doxazosin in their study and noted comparable changes in IPSS scores. MacDonald and co-workers ⁶⁶ in one of the largest series on efficacy of alpha blockers ; a meta-analysis to evaluate the efficacy and adverse effects of Doxazosin for treating lower urinary tract symptoms (LUTS) compatible with benign prostatic obstruction noted a mean magnitude of change in IPSS of 9.2 over a 14week study period and 7.2 for Alfuzosin over the same period. They also noted that the effects of the different alpha adrenergic blockers on patients with moderate IPSS was comparable with slight differences.

In the severe symptom category, open prostatectomy was offered because of surgeons preference. Moreover facilities for transurethral resection of the prostate were not available in both centers at the time of the study. The mean magnitude of change was 24.6 (87%) for the symptom score and 4.0 (79%) for the quality of life. This represents a tremendous improvement in patients

symptoms. The findings were statistically significant (P<0.001). This study has demonstrated that the magnitude of improvement is greater for surgical treatment modalities than for nonsurgical treatment options.

For IPSS change after prostatectomy, others reported mean IPSS improvements of 10.5 to 16 points^{16, 67-70}. Possible reasons for these differences may be late presentation to health care until symptoms are very severe due to the high level of illiteracy in our environment. Most of the patients in this study had no formal education. Differences in study design may be another reason.

Surgical options have the highest degree of symptom improvement ³⁰. Efficacy, in terms of durable improvement in symptom score is superior to other treatment options available for the obstructing prostate gland ³⁰ as was the finding in this study. There may be need for further studies to define long-term outcome.

5.3 Role in outcome prediction

The probability of symptom improvement measured by the IPSS is highest for surgical modality with a predictive value of 87%. However, this does not mean that every patient with symptoms of lower urinary obstruction due to BPH should have surgery since medical therapy with alpha adrenergic blockers has also

been shown to be effective in well selected patients obviating the risks associated with surgical procedures.